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HomeMy WebLinkAboutBP23-054PERMIT # SECTION TYPE OF I JOB LOCP vCO A TCO SPECTION RECORD DATE INSP FOOTING FOUNDATION FRAMING RGH FRAMING INSULATION PLUMBING RGH PLUMBING GAS O SPRINKLER-� ELECTRIC Eff LOW -VOLT 0 ALARM 0 AS BUILT O FINAL DATE /"�� Soo -PA I D f %o- 9 pCO 3i)4 3- 731y OTHER APPROVALS BOT PB - ZBA OTHER �yE 4R 19 Vr CCU.CG.. J�GRi UV W V VILLAGE OF RYE BROOK MAYOR 938 King Street, Rye Brook,N.Y. 10573 ADMINISTRATOR Jason A. Klein (914) 939-0668 Christopher J. Bradbury www.tyebrookny.gov TRUSTEES BUILDING& FIRE INSPECTOR Susan R. Epstein Steven E. Fews Stephanie J. Fischer David M. Heiser Salvatore W. Morlino CERTIFICATE OF COMPLIANCE December 3,2024 Haoyun Feng&Han-Hsuan Liu 27 Mohegan Lane Rye Brook,New York 10573 Re: 27 Mohegan Lane, Rye Brook,New York 10573 Parcel ID#: 135.42-1-23 Building Permit#23-054 issued on 5/2/2023 for Rooftop Solar Shingles This certifies that the rooftop solar shingles,installed under the above captioned permit have been satisfactorily completed. Sincerely, Steven E. Fews Building&Fire Inspector /to D [E V� IE � V E BUILDING� E=" T.MENT For office use only: DD PERMIT#7V30S�f VIL[ AOt OF RYE B*OOK ISSUED: .'S a—c� SEP 17 2024 38 KING STRE UVEOKS YORK 10573 DATE: 9—/7441 FEE: PAID it VILLAGE OF RYE BROOK BUILDING DEPARTMENT APPLICATION FOR CERTIFICATE OF OCCUPANCY,CERTIFICATE OF COMPLIANCES AND CERTIFICATION OF FINAL COSTS TO BE SUBMITTED ONLY UPON COMPLETION OF ALL WORK, AND PRIOR TO THE FINAL INSPECTION ss*sswsttstssttwtsssttw:sstw•r***sssssssst*tww:ss*wssssssstsrertrtsswsttrrtwswtt*twrwwwwsr•wttswswwwtttsswtrtwwsswsswwswswwssstw Address: 27 Mohegan Lane Rye Brook, NY 10573 Occupancy/Use: Residential parcel ID#:! Zone: Owner: Hans Liu Address: 27 Mohegan Lane Rye Brook, NY 10573 P.E./R.A. or Contractor: GAF Energy LLC Address: 5981 Optical Ct San Jose CA 95138 Person in responsible charge: Mike Williams Address: 5981 Optical Ct San Jose CA 95138 Application is hereby made and submitted to the Building Inspector of the Village of Rye Brook for the issuance of a Certificate of Occupancy/Certificate of Compliance for the structure/construction/alteration herein mentioned in accordance with law: STATE OF NEW YORK, COUNTY OF WESTCHESTER as: GAF Energy LLC/Anais Abello being duly sworn,deposes and says that he/she resides at 5981 Optical Ct (Print Name of Applicant) (No.and Street) in San Jose ,in the County of Santa Clara CA in the State of ,that (City/Town/Village) he/she has supervised the work at the location indicated above,and that the actual total cost of the work,including all site improvements, labor,materials,scaffolding,fixed equipment,professional fees,and including the monetary value of any materials and labor which may have been donated gratis was:$ 46,940 for the construction or alteration of. Solar Shingles Deponent further states that he/she has examined the approved plans of the structure/work herein referred to for which a Certificate of Occupancy/Compliance is sought,and that to the best of his/her knowledge and belief,the structure/work has been erected/completed in accordance with the approved plans and any amendments thereto except in so far as variations therefore have been legally authorized,and as erected/completed complies with the laws governing building construction.Deponent further understands that it shall be unlawful for an owner to use or permit the use of any building or premises or part thereof hereafter created,erected,changed,converted or enlarged,wholly or partly,in its use or structure until a Certificate of Occupancy or Certificate of Compliance shall have been duly issued by the Building Inspector as per§250-10.A.of the Code of the Village of Rye Brook. Sworn to be re me this ( Sworn to before me this day of , 20 '> of Z!Pte—of Prope ppli Hans Liu Anais Abello Print Name of Property Owner Pr e f ppIicant N tary Public No Public a cons -- �`otary Public, State of New York Franco Spoldi No. 01 EC6421401 s;12/202 1 Notary Public Qualified in Suffolk County Idy -ommis�,on Expires 8/31/2029 1 Commission Expires August 30, 20 State of Connecticut �E BRC��. cu � 1982 BUILDING DEPARTMENT ❑BUILDING INSPECTOR .11 aASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK ❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573 (914) 939-0668 FAx (914) 939-5801 www.ryebrook.org - - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - - ADDRESS : L C a DATE:12 L Z,.;) Z PERMIT# k �J W L/ ISSUED: 3 7, SECT: BLOCK: LOT: L- j LOCATION: ` 1��� OCCUPANCY: ❑ VIOLATION NOTED THE WORK IS... ❑ ACCEPTED ❑ REJECTED/ REINSPECTION ❑ SITE INSPECTION REQUIRED ❑ FOOTING ❑ FOOTING DRAINAGE ❑ FOUNDATION ❑ UNDERGROUND PLUMBING NOTES ON INSPECTION: ❑ ROUGH PLUMBING ❑ ROUGH FRAMING ❑ INSULATION i ❑ NATURAL GAS ❑ L.P. GAS ❑ FUEL TANK ❑ FIRE SPRINKLER �•, ? 1 l !� d ❑ FINAL PLUMBING ❑ CROSS CONNECTION ❑ FINAL OTHER � � l�j r� e 6rak /vz, O _ : a s � s a O N ar s C = M N � 0 a F+� v) Ln go v b U h+l Cf) :z i. a R; n r , N� i..� o v c W C4 Oul A O ? `4 0 4-4 G� s = L � •� � � W � H oo � � 3 � .�"•C Q 1 O Cp A 0000 V7 1-4 >CIA O� a a� w O 0 o v � y W w b = LO a' T-4CO - r_ "4 z •• 14 CL h� 00 � rl V tJ gg •• p �--� z w en en w i M ci� W CWI� y, o Qoo v %PQ M CIA a 00 a �+ �7cd z W aQ a 0 5 0 O r1� et z O o �' V 0 til rg U � O H a�c •R � U '� oq� � T � O v � �I (A � a W ►y xvi � � .� ro BUILDI .D _ARTMENT a [ [� �,/] VI AGE OF RYtOOK IE L� V 938 KINGUEE BR�#IK,NY 10573 MAC Z 4 2023 -0 t r VILLAGE OF RYE BROOK BUILDING DEPARTMENT *********************rt********rt*rt*******************rtrtrtrtrtrtrt*rtrtrt*********rtrtrtrtsrtrt*rtsrtrt**************rtss*rts*** FOR OFFICE USE ONLY: C Approval Date: Q mi —0s / Applicatitn#��a�7 Approval Signature: ARCHITECTURAL REVIEW BOARD: Disapproved: Date: 3 BOT Approval Date: Case# Chairman: 1591 PB Approval Date: Case# Secretary: 40 ZBA Approval Date: Case# Other: Application Fee: Permit Fees: **************rt*rtrtrtrtrtrtrt*rt*rtrt******rt*rtrtrtrtrtrtrtrtrtrt*rtrtrt*************$******************rtrt******rtrt********rtrt***** APPLICATION TO INSTALL PHOTOVOLTAIC SOLAR ARRAY Application dated: 3—� yQ3 is hereby made to the Building Inspector of the Village of Rye Brook,NY,for the issuance of Permit for the installation of a Photovoltaic Solar Array as per detailed statement described below. ? /7 1. Job Address: 27 Mohegan Lane Rye Brook, NY 10573 SBL: ��5i�� �—aJ Zone: 2 Type,kW&Location of Array,(use additional sheets if necessary I: Residential Roof Intecirated PV Solar System Installation/system size 7.3 kw/ PV Shingles(160)GAF Energy Timberline Solar ES/Inverter(l) Delta M6-TL-US 3.Property Owner: Hans Liu Address: 27 Mohegan Lane Rye Brook, NY 10573 Phone# 574-310-9806 Celt# e-mail oncehorowitz@gmail.com 4.Applicant: GAF Energy LLC/Anais Abello Address:125 Mitchel Blvd Suite D San Rafael, CA 94903 Phone# Cell# 631-413-7314 e-mail NYPermas@gaf.eom anais.abello@gaf.energy 5. Design Engineer: Barun Corp Address: 602 N Atwater Drive Malvern, PA 19355 Phone#610-202-4506 Cell# e-mail chrisk@baruncorp.com 6.Solar Contractor: GAF Energy LLC Address:125 Mitchel Blvd Suite D San Rafael, CA 94903 Phone# Cell# 631413-7314 e-mail NYPermits(dgaf.com anais.abello@gaf.energy 7. Occupancy;(1-Fam.2-1-ain.,Commercial.,etc...)Pre-construction:Existing 1 family Post-construction: Existing 1 family 8. If building is located on a corner lot,which street does it front on: N/A 9. N.Y.State Construction Classification: N.Y.State Use Classification: 10. Construction Type&Location: ()Typical Western Lumber Frame;( )Timber Frame[TC];()Wood Truss[TT]; N/A ( )Pre-engineered wood [PW];Located;( )Floor Framing[F];( )Roof Framing[R];O Floor&Roof Framing[FR];Other: 11. Number of stories: 2 Roof Style:I hip,shed,mansard,etc...) Gable Roof 12. Will a New Roof Be Installed: No ❑ Yes Ll la separate rooEinu,permit is required to rc-roof mi existin.:btuldiqL l 13. Roofing Material&Number of Layers: GAF Energy Timberline Solar ES (46W Solar Shingle) 1 layer I 8/12/2021 14. Will the proposed project disturb 400 sq.ft.or more of land,or create 400 sq.ft.or more of impervious coverage requiring a Stormwater Management Control Permit as per§217 of Village Code? No: 0 Yes: ❑ Area: 15. Will the proposed project require a Site Plan Review by the Village Planning Board as per§209 of Village Code? No: 91 Yes: ❑ (If yes,applicant must submit a Site Plan Application,&provide detailed drawings) 16. Will the proposed project require a Tree Removal Permit as per§235 of Village Code?No: V Yes: ❑ (Ifyes,applicant must submit a Tree Removal Permit Application) 17. Does the proposed project involve a Home-Occupation as per§250-38 of Village Code? No: &�Yes: ❑ Indicate: TIER I:_TIER I1:_TIER III:_ (if yes,a Home Occupation Permit Application is required) 18. What is the total estimated cost of construction: $46,940 (includes reroof) (Note.The estimated cost shall include all site improvements,labor,material,scullolding,fixed equipment,professional fees,including any material and tabu which ma\ he donated gratis-If the final cost exceeds the estimated cost,an additional fee will be required prior to issuance of the CIO) 19. Start Date: tbd Completion Date: tbd This application must bear the notarized signature(s) of the legal owner(s) of the subject property, and the applicant of record in the spaces provided. Any application not properly completed in its entirety andlor not properly signed shall be deemed null and void and will be returned to the applicant. Please note that application fees are non-refundable. STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: I, Anais Abello ,being duly sworn,deposes and states that he/she is the applicant above named, (print name of individual signing as the applicant) and further states that(s)he is the legal owner of the property to which this application pertains,or that(s)he is the, agent/contractor for the legal owner and is duly authorized to make and file this application. (indicate architect,contractor,agent,attorney,etc.) That all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention& Building Code,the Code of the Village {�ofeRye Brook and all other applicable laws,ordinances and regulations. Sworn to'More me this Sworn to before me this /S , j 0 day of ,20 day of M a r c k 20 3 0 ocy otary blic ry Public N y0y• Vim= VO n Z S ature of Property Lywner Si r o Applicant m Print ame of Property Owner h.1N,,mrjfXpphcant Samuel Jararrullo Notary Public My Commission Expires 10/31/2027 State of Connecticut 811 212 02 1 _ 00 N N W ' N N N ` W w 00 N v w t s' Q oQ U a s J A. Ln �. 1-1 z 00 A 14 t O z oCA x J en Q r x �• ✓� ,, ,� z Ln 0�0 (n Q w U a rcc 1 ....� Z � ✓ W :.? r� Z y ►.-� M o • z w ON O w G4 F W a. w z A o z W ot z a Z r w Q a W O O z a,. Q S � i V x u �+ 8 PLO a oZ z W. _ O h U o = w Z a a _ >- O w N z F c� z A C = N o Z F ~ O U z , R BUILDING DEPARTMENT 1 VILLAGE OF RYE BROOK AUG 4 �Q� 3D ' 938 KING ST ET RYE BROOK.NY 10573 RYE VILLAGE OF RYE BROOK 0�- '06_0g BUILDING DEPARTMENT K'v o#n ov ELECTRICAL PERMIT APPLICATION Westchester County Master Electricians License Required � / _ FOR OFFICE USE ONLY BP#: oC7— d�� EP#: � / —/ l0 W Approval Date hilfs 2 Permit Fee: $ Approval Signature: Az Other: DO NOT START WORK or CONSTRUCTION L!NTIL A PERMIT HAS BEEN ISSUED BY THE BUILDING INSPECTOR. THE ADMINISTRATIVE FEE FOR WORK PROGRESSED OR COMPLETED WITHOUT A PERMIT IS 12%OF THE TOTAL COST OF CONSTRUCTION WITH A MINIMUM FEE OF$750.00 YApplication dated, /q_c,� is hereby made to the Building Inspector of the Village of Rye Brook NY,for the issuance of a Permit to install and/or remove electrical equipment, wiring, fixtures,or to perform other high or low voltage electrical work as per the detailed statement described below. By signing this document, the applicant & property owner agree that all electrical work performed will be in conformance with all applicable Federal, State,County and Local Codes. I.Address: 51 MoYfzor Ln SBL: /.3.5; 7d Zone: ��- 2.Property Owner: N2(7}1�j���^}/ Address Phone#:�r}�-7� —q Fj Vb Cell#: email: �r 3.Master Electrician/Licensed Installer:6rWX)ftt6k ��� Y�15 Address: pp11 cc (�� I� Lic.#: Phone#R16-29[ -R41 Cell email:qW(_I G Company Name:r l aeckYl(' _ Q Address: ` 4.Proposed Electrical Work/Fixture Count: 1 `I �V1, c C,�� Y' 1 11 ► Nn ES eY Y - L__U 5.3`d Party Electrical Inspection Agency: aS tS STATE OF NEW YORK,COUNTY OF WESTCHESTER ) as: .being duly swom,deposes and states that he/she is the applicant above named,and does further (print name of individual signing as the applicant) state that(s)he is the for the legal owner and is duly authorized to make and file this application. (Master Electrician/Licensed Installer) The undersigned further states that all statements contained herein are true to the best of his/her knowledge and belief,and that any work performed,or use conducted at the above captioned property will be in conformance with the details as set forth and contained in this application and in any accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention&Building Code.the Code of the Village of Rye Brook and all other applicable laws,ordinances.and regulations. ,� Sworn to before me this Sworn to before me this _ day of 120 da of �6- 20 Signature of Property Owner Signature of Applicant QI h Print Name of Property Owner Print Name of Ap nt SHARI MEL Notary Public NAI �11114p ' 63 Qualified in Westc ester County 6/I/2024 Commission Expires January 29,267i7 STATE WIDE INSPECTION SERVICES, INC. •:0 • • SWIS • : APPLICATION tel 845.202.7224 1 fax 914.219.1062 • Office Use Elect. Permit# �c� / Date Bldg Permit# 5 Sq Ft Plumbing Permit# Final Certificate# City/Village 6r� Ziplr t 7 Building Dept. y� countyl.(JP C !� / Address �(/jr� 1 Cross Street F. Sectioy 3 j L� Block / Lot; 3 Owner Name/Address(If different than above) S L �I Contact Number 5 7(1 : C-j ❑Basement ❑1st Fl. ❑2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. ❑Garage ❑Attic ❑Outside ❑/Residential ❑Commercial Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/0 Detector Hood Trash Compact Amt Amps Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch SERVICE Amperage #Panels 1P 3P #Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑Repair 1-1 Overhead ❑Upgrade ❑ Disconnect Utility ID# ❑Con Ed ❑NYSEG ❑Central Hudson ❑ Orange/Rockland PHOTOVOLTAIC SYSTEM PV Modules Inverters AC Disconnect ]unction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect ❑Legalization Safety Inspection ❑Consultation P � sd/ar Sl h� 1- � 1� p UE L EE I A.UG 14 2024 LU) VILLAGE OF OK BUILDING DEPARTMENT This application is valid for one(t)year from the date received by SWIS.This application is intended to cover the above listed items to be inspected,if at any time of inspection additional items have been installed,you are authorized to make the Inspection and adjust the fee for the additional Items Inspected.The applicant declares that there is no open applications for the above address with any other Inspection company.The applicant, owner or authorized agent agrees to all the above terms and conditions as set forth for the application. Email Address M Q / C/ "P/�,.C O'l( , /� �'i Name 6/h�7�� License# Date Signature Lry Address (—r City/State s Zip Company ����� '� Phone#i � DE C E ��E State Wide Inspection Services 1080 Main Street 2 7 2024 Fishkill, NY 12524 SEP 845 202-7224 Phone 914-219-1062 Fax STATE WIDE INSPECTION SERVICES VILLAGE OF RYE BROOK Email: office@swisny.com BUILDING DEPARTMENT Website: www.swisny.com Service With Integrity BY THIS CERTIFICATE OF COMPLIANCE STATE WIDE INSPECTION SERVICES CERTIFIES THAT: Upon the application of: Upon Premises Owned by: EZ Electric Haoyun Feng& Han-Hsuan Liu Emmanouil Zervakis 27 Mohegan Lane 27 North Rockland Avenue Rye Brook, NY 10573 Congers, NY 10920 Located at: 27 Mohegan Lane, Rye Brook, NY 10573 Section: Block: Lot: Electrical Permit Number: EP-24-168 135.42 11 1 j 1 23 71 Certificate Number: 2024-6710 Building Permit Number: BP 23-054 A visual inspection of the electrical system was conducted at the Residential occupancy described below.The electrical system consisting of electrical devices and wiring is located in/on the premises at: 27 Mohegan Lane, Rye Brook, NY 10573 The Photovoltaic System was inspected in accordance with the NYS and NFPA 70-2017 and the detail of the installation,as set forth below,was found to be in compliance on the 25`h Day of September 2024. Name Quantity Rating Circuit Type Timberline Solar ES 160 RSD Boxes 06 Backfeed Breaker 01 30 Amp Inverter 01 30 Amp Non-Fused Disconnect 01 30 Amp Officer: Frank). Farina This certificate may not be altered in any way and is validated only by the presence of a seal at the location indicated.This certificate is valid for work performed on the date of inspection only. Ir RFIcE�wE DD BARON CORP OCT - 4 2024 Registered A Chris Kim Engineering P.C. VILLAGE OF RYE BROOK BUILDING DEPARTMENT October 3,2024 RE: POST INSTALLATION AFFIDAVIT Project Address: HANS LIU RESIDENCE 27 MOHEGAN LANE RYE BROOK, NY 10573 Subject: Post Installation Affidavit To the Village of Rye Brook, I, Yuri Yurianto, have reviewed the site installation on 10/3/2024 and certify that the installation meets the Village of Rye Brook approved building plans and all manufacturers specifications, 2020 NYSEBC/NYSBC codes,the residential code of NYS and the provisions of ASCE 7-16. On the above reference project,the structure has been reviewed for additional loading due to the installation of the GAF Timberline Solar ES to the roof. The structural review, including the plans and calculations only apply to the section of roof that is directly supporting the Solar ES system and its supporting elements. The demand loading on the structure directly supporting the additional gravity loading due to the GAF Timberline Solar ES had been reviewed post installation and determined to be in accordance with the requirements of the following code;2020 NYSEBC/NYSBC,2020 NYSRC and ASCE 7-16. The letter shall serve as a certification that the installation meets the requirements of the approved permit drawings. Please feel free to contact me with any further questions. Sincerely, Of NE*yD NY Gj -to Y�R/ �� Digitally signed by J� `• 0 Yunanto Yunanto * iDN:cn=Yurianto Yurianto c=US o=Texas 1 t/ lO Reason:I am the author r i ` of this document Location: Date:2024-10-03 (� 101980 (C 10:27-05:00 By Yuri at 10:27:04 AM, 101312024 This document is the property of Barun Corp and cannot be reproduced without prior consent.It is site specific and shall not be transferred to any other property,property owner,person(s),or entity.This document may include an expression of professional opinion by the engineer of record,which is based on his or her best knowledge, information provided by others,and belief.Other professionals may have different opinions Barun Corp reserves the right to amend and/or supplement this document in the event additional information be uncovered or made available Barun Corp I Design and Engineering 1610.202.4506 1 chrisk@baruncorp.com I www.baruncorp.com - y�.,".`� � 'Z.4♦ " .k �{y1♦' Mtn"T�rl � - .� �!<� ?4�p� � 3.�i r � c s:_ S�, •'k �i���Y I ray. w7. 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A$ Mc ''ay' f A�Qi ham » ~ -_C d��i��.� _ �j`FS,. ,� ���[ A`R. � :t•- \ • kh... �.i`t4. • �dit 4� ��..v,�lDvv"� n�,t w+r i y` a•,� Y3 r � J. r C t 115, -fa •r2 - ^ S. t - i d y A' '1 i. f - j� i 15. t t %' >i P W , s r' r t/`lYf� _b .t' � e ! z � r Ar S 1-. at a' . * Building Permit Check List&Zoning Analysis Address: o�p — SBL• Zone: � se 2� Const.Type: Other. Submittal Date Revisions Submittal Dates: Applicant: r{`j Nature of Work Reviews:ZBA• B' BOT• Other. OK �j.� (�'FEFS:Filing. BP: �, C/O: Flood Plane: Legalization: ( ) ( ) APP. Dated: Notarized: SBL Truss I.D. Cross Connection H.O.A.: ( ) ( ) Scenic Roads: Steep Slopes: Wetlands: Storm Water Review: Street Opening. ( ) ( ) ENVIRO:Long. Shore Fees: N/A: ( ) ( ) SITE PLAN:Topo: Site Protection: S/W Mgmt: Tree Plan: Other. ( ) ( ) SURVEY:Dated Current: ArchivaL Sealed.' ealed Unacceptable: PLANS:Date Stamped: Sealed: Copies?� Electronic "'Other License: Workers Comp:,i Liability Comp.Waiver. Other. ( ) ( ) CODE 753#: Dated: N/A: (� ( ) HIGH-VOLTAGE ELECTRICAL Plans: Permit N/A: Other. ( ) ( ) LOW-VOLTAGE ELECTRICAL Plans: Permit: N/A Other: ( ) ( ) FIRE ALARM/SMOKE DETECTORS:Plans: Pemut H W.I.C.:_Battery _Other. ( ) ( ) PLUMBING Plans: Permit: Nan Gas: LP Gas: N/A/: Other. ( ) ( ) FIRE SUPPRESSION:Plans: Permit N/A: Other. ( ) ( ) H.V.A.C.: Plans: Permit: N/A. Other. ( ) ( ) FUEL TANK:Plans: Permit Fuel Type: Other. O O 2020 NY State ECCC: N/A: Other. ( ) ( ) Final Survey Final Topo: RA/PE Sign-off Letter. As-Built Plans: Other. ( ) ( ) BP DENIAL LETTER: C/O DENIAL LETTER: Other. ( ) ( ) Other. ( t RB mtg.date approval;- notes: ( )ZBA mtg.date: approval;- notes: ( )PB mtg. date: approvaL• notes: REQUIRED EXISTING PROPOSED NOTES APPR®VE4 Circle: � Date:APR 2 4 202 Fr n e Front Front: sides: R&ar. Main Cov: Accs.Cov: Ft.HS : Sd.H Sb: S Tot Imp Paz Hight/Stories: notes: wo VCA f- C P 1S _jD1 BUILDIP6: ARTMENT Di VILLA ,. OF RYE�RROOK MAR 2 4 2023 938 KING ET RYE BROUK,NY 10573 4 9 VILLAGE OF RYE BROOK BUILDING DEPARTMENT ARCHITECTURAL REVIEW BOARD CHECK LIST FOR APPLICANTS This form must be completed and signed by the applicant of record and a copy shall be submitted to the Building Department prior to attending the ARB meeting. Applicants failing to submit a copy of this check list will be removed from the ARB agenda. Job Address: 27 Mohegan Lane Rye Brook, NY 10573 Date of Submission: Parcel ID A 130.'y3 —1—J 3 Zone: —/ 4 Proposed Improvement Describe in detail): Residential Roof Integrated PV Solar System Installation/ APPLICANT CHECK LIST: system size 7.36kw/ PV Shingles(160) GAF Energy Timberline Solar E / MUST BE COMPLETED BY THE APPLICANT Inverter(1) Delta M6-TL-US The following items must be submitted to the Building Department by the applicant-no exceptions. Property Owner: Hans Liu 1. (V)Completed Application 2. (0 Two(2)sets of sealed plans. (one full size (maximum Address: 27 Mohegan Lane Rye Brook, NY 10573 allowable plan size=36"x 42") and one I I"xl7") 574-310-9806 3. ( )Two(2)copies of the property survey.N/A Phone# 4. Two(2)copies of the proposed site plan. Applicant appearing before the Board: 5. One electronic/disc copy of the complete GAF Energy LLC/Anais Abello application materials. 6. (vj Filing Fee. Address:125 Mitchel Blvd Suite D San Rafael, CA 94903 7. ( )Any supporting documentation. 631-413-7314 8. ( ) HOA approval letter. (ifopplicable) N/A Phone# 9. (%6 Photographs. Architect/Engineer: Barun Corp 10.(0 Samples of finishes/color chart. (a sample board or Phone#610-202-4506 model may bepr(willebringlsolarr shingle o the meeting) By signature below, the owner/applicant acknowledges that he/she has read the complete Building Permit Instructions&Procedures, and that their application is complete in all respects. The Board of Review reserves the right to refuse to hear any application not meeting the requirements contained herein. Sworn to befor me this Sworn to before me this day of , 20 �i of /' c , 20 Si re o //operty Owner Signature of pplic tII^^ I��HS l-lu AY�(At r)L 1 Print Name of Property Owner int Name of Applicant Zt'/.LA Notary Public Notary uP blic LISA M.SCHUCH Notary Public.State of New York No.01SC6387575 Samuel Jaramillo 1 Quatn E in es 01kFeb County 20_2 1 f COmmissipn Expires February I Notary Public My Commission Expires 10/31/2027 State of Connecticut 11 8/12/2021 �yE BR(�v� Village of Rye Brook ML MR endaFB SE 0� ` ��J �, Architectural Review Meeting AC SF�t`.y Wednesday,April 19,2023 at 7:30 PM J Village Hall,938 King Street M V J 1. ITEMS: 1.1. ARB23-025 (Consent Agenda) James Luciano&Helen Luciano 14 Lyon Street Rooftop solar array. 1.2. ARB23-026 (Consent Agenda) Karin Yapur 30 Tamarack Road Rooftop solar array. 1.3. ARB23-027 (Consent Agenda) Han-Hsuan Liu&Haoyun Feng 27 Mohegan Lane Rooftop solar array. 1.4. ARB23-028 (Consent Agenda) Victor Paterno&Annemarie Paterno 15 Old Orchard Road Replace front walk,entry steps,driveway retaining wall and re-pave driveway. 1.5. ARB23-029 (Consent Agenda) Christopher Davis&Lauren Davis 1 Whippoorwill Road Replace front walk,front steps,re-do concrete patio with pavers and install gas firepit. 1.6. ARB23-030 (Consent Agenda) Jonathan Fox&Alison Fox 1 Country Ridge Circle 6'&4'high white vinyl fence and gates. 1.7. ARB23-031 (Consent Agenda) Cape Eland LLC 12 Rock Ridge Drive 4'high welded wire fence and gates. 1.8. ARB23-032 (Consent Agenda) Scott Stern&Bonnie Stern 79 Greenway Close 3'high split rail fence and gate. 1.9. ARB23-033 (Consent Agenda) Fabricio Denadae&Lucian Chieus do Amaral 110 Brush Hollow Close Replace decking on existing rear deck. • � t Architectural Review Board April 19,2023 Consent Agenda r� t Approvals: Motion Second 'l _nA L- Abstention Aye;— Nay; Adjournment; Notes 1.10. ARB23-034 (Amendment to Prior Approval) Matan Dvir&Ilana Dvir 1 Dorchester Drive Dormer modifications. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.11. ARB23-035 Eric Goldstein&Rebecca Kleban 5 Berkley Drive Rear covered porch,stone walkway and drainage. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.12. ARB23-036 Scott Hirsch&Christine Staeger-Hirsch 1 Beacon Lane Remove rear door,install window.Remove side bay window,install sliding doors. Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes 1.13. ARB23-037 (Amendment to Prior Approval) Win Ridge Realty LLC 166 South Ridge Street New store front"Amazing Lash Studio" Approvals: Motion Second Abstention Aye; Nay; Adjournment; Notes NEXT MEETING: May 17,2023 BA R U N CORP F:2 4 2Q23 ( March 10,2023 j VILLAGE OF RYE BROOK _BUILDING DEPARTMENT RE: CERTIFICATION LETTER Project Address: HANS LIU RESIDENCE 27 MOHEGAN LANE RYE BROOK,NY 10573 Design Criteria: Applicable Codes=2020 NYSEBC/NYSBC,2020 NYSRC,ASCE 7-16 and 2018 NDS Risk Category=II Wind Speed=120 mph,Exposure Category C,Partially/Fully Enclosed Method Ground Snow Load=30 psf MP 1&2:Roof DL=7 psf,Roof LL/SL=23 psf(Non-ES),Roof LL/SL=17.3 psf(ES) MP 3:Roof DL=7 psf,Roof LL/SL=23 psf(Non-ES),Roof LL/SL=18.1 psf(ES) To Whom It May Concern, A structural evaluation of loading was conducted for the above address based on the design criteria listed above. Existing roof structural framing has been reviewed for additional loading due to installation of Timberline Energy Shingles on the roof.The structural review applies to the sections of roof that is directly supporting the Timberline Energy Shingles. Based on this evaluation,I certify that the alteration to the existing structure by installation of the Timberline Energy Shingles meets the prescriptive compliance requirements of the applicable existing building and/or new building provisions adopted/referenced above. Additionally,the Timberline Energy Shingles assembly(including attachment hardware)has been reviewed to be in accordance with the manufacturers specifications and to meet and/or exceed the requirements set forth by the referenced codes. Installer shall verify existing roof framing(including connection)is in suitable condition and does not exhibit any signs of structural damage or deficiency.Installer verification of the mounting planes noted above is required because some or all of the framing was not observed prior to the structural evaluation performed for this report. Sincerely, F NEW ,' NY C yu'i �Ir- Digitally signed by Yudanto Yunanto �J * n t0 D-U cn=Yudanto Yudento c= S o=UnaRliated ou=A01410D000001761107 C8F250DD0A7A2 Y ri rlt0 r Reason:I am the author of this document Location'. Date:2023-03-10 08:23-06:DO s�o 101980 AROFESS01 By Yuri at 8:22:54 AM,311012023 This document is the property of Barun Corp and cannot be reproduced without prior consent.It is site specific and shall not be transferred to any other property, property owner,person(s),or entity.This document may include an expression of professional opinion by the engineer of record,which is based on his or her best knowledge,information provided by others,and belief.Other professionals may have different opinions.Barun Corp reserves the tight to amend and/or supplement this document in the event additional information be uncovered or made available. Barun Corp I Design and Engineering 1610.202.4506 1 chrisk@baruncorp.com I www.baruncorp.com 1/6 BARUN CORP RESULTS SUMMARY"100" HANS LIU RESIDENCE,27 MOHEGAN LANE,RYE BROOK,NY 10573 MOUNTING • MOUNTING PLANE ROOF PITCH RESULT GOVERNING ANALYSIS MP 1&2 25' OK NYSEBC IMPACT CHECK MP 3 23' OK NYSEBC IMPACT CHECK Limits of Scope of Work and Liability: The existing structure has been reviewed based on the assumption that it has been originally designed and constructed per appropriate codes. The structural analysis of the subject property is based on the provided site survey data. The calculations produced for this structure's assessment are only for the roof framing supporting the proposed PV installation referenced in the stamped planset and were made according to generally recognized structural analysis standards and procedures. All PV modules, racking and attachment components shall be designed and installed per manufacturer's approved guidelines and specifications. These plans are not stamped for water leakage or existing damage to the structural component that was not accessed during the site survey. Prior to commencement of work, the PV system installer should verify that the existing roof and connections are in suitable condition and inspect framing noted on the certification letter and inform the Engineer of Record of any discrepancies prior to installation.The installer should also check for any damages such as water damage, cracked framing, etc. and inform the Engineer of Record of existing deficiencies which are unknown and/or were not observable during the time of survey and have not been included in this scope of work.Any change in the scope of the work shall not be accepted unless such change,addition,or deletion is approved in advance and in writing by the Engineer of Record. Barun Corp I Design and Engineering 1610.202.4506 1 chrisk@baruncorp.com I www.baruncorp.com 2/6 LOAD CALCULATION BARUN CORP MP 1&2 HANS LIU RESIDENCE,27 MOHEGAN LANE,RYE BROOK,NY 10573 ENERGY SHINGLES • • LOAD Energy Shingles Weight = 2.50 psf Hardware Assembly Weight = 0.50 psf Total Energy Shingles ES-DL= 3.00 psf ROOF DEAD LOAD Existing Roofing Material Weight Composite Shingle Roof 1 Layer(s) = 2.50 psf Underlayment Weight = 0.50 psf Plywood/OSB Sheathing Weight = 1.50 psf Framing Weight = 0.73 psf No Vaulted Ceiling = 0.00 psf Miscellaneous = 1.50 psf Total Roof Dead Load R-DL= 6.70 psf REDUCED ROOF LIVE LOAD Roof Live Load Lo= 20.00 psf Member Tributary Area At< 200 ftZ MP 1&2 Pitch 25'or 6/12 Tributary Area Reduction Factor R1= 1.00 Roof Slope Reduction Factor R2= 0.93 Reduced Roof Live Load,Lr=Lo(Rl)(112) Lr= 18.50 psf SNOW LOAD Ground Snow Load pg= 30.00 psf Effective Roof Slope 25' Snow Importance Factor Is= 1.00 Snow Exposure Factor Ce= 1.00 Snow Thermal Factor Ct= 1.10 Minimum Flat Roof Snow Load pf-min= 0.00 psf Flat Roof Snow Load pf= 23.10 psf SLOPED ROOF SNOW LOAD ON ROOF(Non-Slippery Surfaces) Roof Slope Factor Cs-roof= 1.00 Sloped Roof Snow Load on Roof ps-roof= 23.10 psf SLOPED ROOF SNOW LOAD ON ENERGY SHINGLES(Unobstructed Slippery Surfaces) Roof Slope Factor Cs-ES= 0.75 Sloped Roof Snow Load on Energy Shingles ps-ES= 17.30 psf 77 Barun Corp I Design and Engineering 1610.202.4506 1 chrisk@baruncorp.com I www.baruncorp.com 3/6 IMPACTNYSEBC BARON CORP MP 1&2 HANS LIU RESIDENCE,27 MOHEGAN LANE,RYE BROOK,NY 10573 EXISTING WITH ENERGY SHINGLES Roof Dead Load(DL)= 6.70 9.70 psf Roof Live Load(Lr)= 18.50 0.00 psf Roof Snow Load(SL)= 23.10 17.30 psf EXISTING WITH ENERGY SHINGLES (DL+Lr)/Cd= 20.16 10.78 psf (DL+SL)/Cd= 25.91 23.48 psf Maximum Gravity Load= 25.91 23.48 psf Load Increase(%)_ -9.40% The requirements of section 806.2 of 2020 NYSEBC are met and the structure is permitted to remain unaltered. Barun Corp I Design and Engineering 1610.202.4506 chrisk@baruncorp.com I www.baruncorp.com 4/6 LOAD CALCULATION BARUN CORP MP3 HANS LIU RESIDENCE,27 MOHEGAN LANE,RYE BROOK,NY 10573 ENERGY SHINGLES DEAD • • • • Energy Shingles Weight = 2.50 psf Hardware Assembly Weight = 0.50 psf Total Energy Shingles Weight ES-DL= 3.00 psf ROOF DEAD LOAD(R-DL) Existing Roofing Material Weight Composite Shingle Roof 1 Layer(s) = 2.50 psf Underlayment Weight = 0.50 psf Plywood/OSB Sheathing Weight = 1.50 psf Framing Weight = 0.73 psf No Vaulted Ceiling = 0.00 psf Miscellaneous = 1.50 psf Total Roof Dead Load R-DL= 6.70 psf REDUCED ROOF LIVE LOAD Roof Live Load Lo= 20.00 psf Member Tributary Area At< 200 ft2 MP 3 Pitch 23`or 5/12 Tributary Area Reduction Factor R1= 1.00 Roof Slope Reduction Factor R2= 0.95 Reduced Roof Live Load,Lr=Lo(R1)(R2) Lr= 19.00 psf SNOW LOAD Ground Snow Load pg= 30.00 psf Effective Roof Slope 23' Snow Importance Factor Is= 1.00 Snow Exposure Factor Ce= 1.00 Snow Thermal Factor Ct= 1.10 Minimum Flat Roof Snow Load pf-min= 0.00 psf Flat Roof Snow Load pf= 23.10 psf SLOPED ROOF SNOW LOAD ON ROOF(Non-Slippery Surfaces) Roof Slope Factor Cs-roof= 1.00 Sloped Roof Snow Load on Roof ps-roof= 23.10 psf SLOPED ROOF SNOW LOAD ON ENERGY SHINGLES(Unobstructed Slippery Surfaces) Roof Slope Factor ICs-ES= 0.78 Sloped Roof Snow Load on Energy Shingles I ps-ES= 18.10 psf Barun Corp I Design and Engineering 1610.202.4506 1 chrisk@baruncorp.com I www.baruncorp.com 5/6 NYSEBC IMPACT CHECK BARON CORP MP 3 HANS LIU RESIDENCE,27 MOHEGAN LANE,RYE BROOK,NY 10573 EXISTING WITH ENERGY SHINGLES Roof Dead Load(DL)= 6.70 9.70 psf Roof Live Load(Lr)= 19.00 0.00 psf Roof Snow Load(SL)= 23.10 18.10 psf EXISTING WITH ENERGY�IHjIN�G�L�E"S (DL+Lr)/Cd= 20.56 10.78 psf (DL+SL)/Cd= 25.91 24.17 psf Maximum Gravity Load= 25.91 24.17 psf Load Increase(%)_� -6.71% OK The requirements of section 806.2 of 2020 NYSEBC are met and the structure is permitted to remain unaltered. Barun Corp I Design and Engineering 1610.202.4506 chrisk@baruncorp.com I www.baruncorp.com 6/6 GAF ENERGY n r .. HIV- !� l A , +.". .! .t' �' �• _ +.SFr.,y � i� �. www. soIarroofingwestchester . com ii BMW Group inc. ROOFING • SOLAR SOLAR CEPTIFIE. Proposal for Roof Replacement with GAF Timberline Solar Roofing System A'A Prepared for: Prepared on: Hans Liu January 2011, 2023 27 Mohegan Ln Rye Brook, NY 10573 222 PURCHASE ST SUITE 201 RYE, NY 10580 TEL:914-403-6752 We propose to furnish the necessary labor, material and equipment required to do the roofing above named project as follows: DEMOLITION AND ROOF DECK SHEETING -Remove existing asphalt shingles and underlayment to the roof deck sheeting and dispose of the material off site -Inspect existing roof deck sheeting (Note:Any replacement of existing sheeting will be an additional charge of$100 per 4'x8'sheet.Customer will be notified of existing damage. -Furnish dumpster -Complete job clean up TIMBERLINE SOLAR ROOFING SYSTEM INSTALLATION ( 160 solar shingles-system size 7.36 kW DC) -Engineer and design Solar system ( Electrical and structural analysis) -Furnish material and install red copper drip edge for entire roof perimeter.This prevents insects from entering the space between the deck and the fascia board. -Furnish material and install GAF Weather Watch membrane at all eaves and valleys Note: Membrane shall be installed along all eaves and shall extend past the interior wall line minimum of 24 inches to provide protection against damage from ice dams. 8& W Group Inc. will install 6 feet of membrane at all eaves.) -Furnish material and install GAF Feltbuster roofing underlayment for roof area not covered by Weather Watch membrane.This helps provide long lasting protection against wind-driven rain from infiltrating under your shingles. -Furnish material and install GAF WeatherBlocker shingles at all eaves and rakes.This is to prevent shingle blow offs. -Furnish material and install GAF Timberline Solar HD architectural style asphalt shingles and Timberline Solar Energy shingles with all hardware for entire steep slope roof area (Note:Shingles will be installed in strict accordance with the manufacturer's specifications and shall be fastened using six nails per shin le. -Furnish material and install GAF Cobra ridge vent at all ridges.This is for effective ventilation to keep houses cooler in the summer. -Furnish material and install GAF Timbertex hip and ridge shingles at all hips and ridges -Furnish material and install new aluminum pipe boots on all external vent pipes -Connect solar shingles to inverter ($5,000 Value) -Furnish GAF Solar Max and Golden Pledge Warranties ($1,200 Value) -Apply and obtain building and electrical permits -Facilitate interconnection approval with utility and net meter change -Perform testing to help ensure installation is complete and Solar system is fully operational -Schedule with building inspector to perform necessary inspections All the above,for the sum of:Forty Six Thousand Nine Hundred Forty Dollars-$46,940 222 PURCHASE ST SUITE 201 1 RYE,NY 105801 TEL:914-403-6752 .You may be able to apply the 30%Federal Tax Credit to your cash purchase or loan amount. GAF Energy and B &W Group Inc.do not provide tax or legal advice. You should consult with your tax advisor for more information.There are no guarantees,warranties or representation regarding the production, performance, utility rate increases,workmanship, or any other data relating to GAF Timberline Solar.This proposal is not an approval for installation or financing. PAYMENT SCHEDULE: 1 s'payment (deposit) -$5,000 paid before ordering permitting package 2"d payment ( deposit) -$ 16,000 paid before ordering all needed materials 31d payment- $ 7,600 when 30%of roof is installed 41h payment- $ 7,700 when 60%of roof is installed 51h payment- $ 7,700 when roof and solar shingles are installed 6th payment-$2,000 when new solar system is connected to an inverter with all disconnects installed 7th payment-$940 when job is completed and connected to the grid NOTES -B &W Group Inc.will provide GAF Solar Max and Golden Pledge Limited Warranty backed by GAF ( 25 year workmanship coverage and lifetime material coverage. ) -GAF Golden Pledge and Solar Max Warranty will be registered online and proof of warranty will be emailed after completion and final payment. -Price does not include removal and replacement of any siding or exterior trim -B &W Group Inc.will meet all insurance requirements for general liability, automobile liability and workers compensation with adequate limits. -B &W Group Inc.will not be responsible for pre existing damages and nail pops created from men working on the roof -Pricing is good for 30 days -Consumer may cancel the contract at any time prior to midnight of the third business day after the contract is signed. Thank you for the opportunity to provide you with this estimate. Ziggy Bobrowski President Approved by: B &W Group Inc. lylalid Z_'C 4 Date: 1/29/2023 Date: 222 PURCHASE ST SUITE 201 1 RYE,NY 10580 1 TEL:914-403-6752 ID EC� i AWE DD MAR 2 4 2Q23 GM VILLAGE OF RYE BROOK ENERGY BUILDING DEPARTMENT RE: Solar Permit Submission for: 27 Mohegan Lane Rye Brook NY 10573 To Whom It May Concern, I have enclosed the required documents for the solar roof project at the above property address. Once review is completed and if documents are approved, please mail me the approved plans and permit to the address listed below. Please do not hesitate to contact me with payment request and if any further action is required. Anais Abello 105 Harrison Ave Miller Place, NY 1176-1 Thank you for your help. Best, Anais Abello Permit Associate anais.abello@gaf.energy papermits@gaf.com 631-413-7314 125 Mitchell Blvd, Suite D, San Rafael, CA 94903 www.gaf.energy co)s ►lid . .. .. . .. . . . . . . . . . . . �+ y cz .,w L •cc O m a. > C k N - r ea a C U 4- O` �— tC 7CC CD a O y h v O a� =r•. 07 0 C 0 _ ^i•� v F� •,� Ch U ction s : tv'rO Q µ LL ► O _ U) e as 4. LO y N V u Ilk V, W4.01.4"' 21�0 MAR.'*6 w vii, V �tn_V V V . y`r) .ram .. y�.,. .'vr�n "4J�' +/•y�+- .'N�ti e%M DATE(MMIDD/YYYY) ACORN® CERTIFICATE OF LIABILITY INSURANCE 03103/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: 445 SOUTH STREET (A/CNN.Ext): _ __- — - _ AIC,No): MORRISTOWN,NJ 07%2-1%6 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN101442967-GAF E-GAW-22-23 _ INSURER A:American Zurich Insurance Company 40142 INSURED GAF Energy LLC INSURER B:Zurich American Insurance Company 16535 - 125 Mitchell Blvd#D INSURER C: San Rafael,CA 94903 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-011567650-01 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MWDD MWDD LIMITS B X COMMERCIAL GENERAL LIABILITY GLO2165695-26 11/01/2022 11/01/2023 EACH OCCURRENCE $ 2,000,000 DAGE TO CLAIMS-MADE OCCUR PRREMISES EaE NTED l .. occurrence $ _ 500,000 MED EXP(Any one person) y 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 6,000,000 OTHER: Products-Camp/Op OCC $ 3,000,000 B AUTOMOBILE LIABILITY BAP 2165690-26 11/01/2022 11/01/2023 COMBINED SINGLE LIMIT Ea accident $ 3,000,000 IXX ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED 1 1 RETENTION$ t A WORKERS COMPENSATION WC 2165693-27(ADS) 11101/2023 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANYPROPRIETOR/PARTNER/EXECUTNE Y/N WC3036795-16(WI,NE) 11I01/2022 11/01/2023 2000p00 OFFICER/MEMBER EXCLUDED? NI NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under 2 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Village of Rye Brook SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 938 King Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rye Brook,NY 10573 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '112a-zc,Gc 2tSr� �`cc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured 973-628-3000 GAF Energy LLC 125 Mitchell Blvd#D 1 c. NYS Unemployment Insurance Employer Registration Number of San Rafael,CA 94903 Insured 54-026870 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e..a Wrap-Up Policy) Number 22-2934562 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AMERICAN ZURICH INSURANCE COMPANY Village of Rye Brook 3b.Policy Number of Entity Listed in Box"1 a" 938 King Street Rye Brook, NY 10573 WC 2165693-27 3c. Policy effective period 11/1/2022 to 11/1/2023 3d.The Proprietor,Partners or Executive Officers are �✓ included.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box 1a" for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: JP Petrucci (Print name of authorized representative or licensed agent of insurance carrier) Approved by: Pam". 03/03/2023 (Signature) (Date) Underwriter Title. Telephone Number of authorized representative or licensed agent of insurance carrier: Underwriter Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov �l 01 Ul D w . 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